Employee Benefits Overview

2020

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TABLE OF CONTENTS

Benefits You Can Depend On ........................................................................................................................... 2

What’s New for 2020? .................................................................................................................................... 3

Join Us At A Health Fair! ................................................................................................................................. 5

Benefit Plan Information for 2020 .................................................................................................................... 6

Who Can You Cover? ...................................................................................................................................... 7

Making the Most of Your Benefits Program ........................................................................................................ 8

Medical ....................................................................................................................................................... 9

Prescription Drugs ....................................................................................................................................... 10

Dental ........................................................................................................................................................ 11

Vision ........................................................................................................................................................ 12

Cost of Coverage ......................................................................................................................................... 13

Life and Disability Insurance ......................................................................................................................... 15

Voluntary Accident and Critical Illness Insurance ............................................................................................. 16

Wellness Benefit At A Glance ........................................................................................................................ 17

Voluntary Insurance Rates ............................................................................................................................ 18

Other Programs ........................................................................................................................................... 20

Health Savings Account ................................................................................................................................ 22

Flexible Spending Account ............................................................................................................................ 23

For Assistance ............................................................................................................................................ 25

Key Terms .................................................................................................................................................. 26

Important Plan Notices and Documents ........................................................................................................... 28

Appendix .................................................................................................................................................... 29

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Benefits You Can Depend On

The Santa Barbara County Superior Court has a benefits program that provides you with the best coverage that is simple and comprehensive. We offer programs that protect your health, your money, your family and help you find balance between your concerns at work and at home. We also know the value of understanding your coverage so that you know how to get care, when you need it, at the lowest cost. With the tools and information in this booklet and related resources, we hope to help you be well today and work towards a healthy and secure future.

The Court understands that comparing benefit plans, features and costs can be complicated. This booklet provides information that will help simplify your decision making process. It is a summary of your benefits and does not provide a complete description of all benefit provisions. For more detailed information, please refer to your Evidence of Coverage documents (EOCs). The Evidence of Coverage documents determine how all benefits are paid.

The benefits in this summary are effective:

January 1, 2020 - December 31, 2020

Open Enrollment Period: October 1 to October 31, 2019.

Medicare Part D Notice: If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see the Annual Notices on the Court’s website, www.sbcourts.org/gi/hr/benefits.asp for more details.

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What’s New for 2020?

VOYA – Voluntary Hospital Confinement Indemnity Plan

Voya is offering their Compass Hospital Confinement Indemnity plan which provides a benefit for a hospital stay. This voluntary benefit is separate from your Blue Shield hospital benefit. The new Voya plan pays a daily benefit if you have a covered stay in a hospital, critical care unit or rehabilitation facility. The benefit is determined by the type of facility and the number of days you stay. You can use the lump sum payment for any purpose such as deductible, copays or everyday expenses like utilities and groceries. Plan rates are noted on page 18.

Plan highlights:

• Guarantee issue – no medical question or tests required • Flexible – you can use the benefit payments for any purpose you like • Portable – you can take the policy with you if you leave your employer or retire

Benefit

Initial Hospital admission $1,000

Hospital $100 per day up to 30 days per confinement

Critical Care Unit $200 per day up to 15 days per confinement

Rehabilitation Facility $50 per day up to 30 days per confinement

Pre-existing condition limitation None

Age reduction None

Portability You can take this policy with you if you leave the Court

Wellness Benefit

Employee $50, once a year

Spouse $50, once a year

Child $25 per child, to a maximum of $100, once a year

The Wellness benefit provides an annual amount if you complete a preventive health screening test. Refer to page 17 for information on what are Preventive health screening tests.

If viewing electronically, click on the icon to view a video on the Hospital Indemnity Plan or go to our website where you will find an electronic copy of this booklet.

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Express Scripts – Smart90 Program

What is the Smart 90 program?

This program is available to Express Scripts members that are taking maintenance medication on a daily basis. Express Scripts now gives you a choice on where to dispense a three month supply of your maintenance drugs. You can:

1. Fill your prescription through home delivery from the Express Scripts Pharmacy OR 2. Fill your prescription at any CVS or Walgreens pharmacy

Relax with 90-say supplies.

The bottom line:

Be like Kyle – order a 90-day supply of your maintenance medication. Now you have two convenient options through Smart90.

Here is how your prescription plan works:

1. If you are prescribed a daily maintenance medication, you have two 30-day fills at your local pharmacy.

2. After two refills, you must move to a 90-day supply through Express Scripts home delivery pharmacy or at your local CVS or Walgreens.

3. Let your doctor know that you need a 90-day supply when you are prescribed a daily maintenance medication. The doctor can write a prescription for 12 months and the medication can be refilled every 90 days.

VSP – Walmart now an option

VSP is adding Walmart as a provider where you can obtain your glasses. The Walmart frame allowance will be $70, contact lenses will the same as current benefit (up to $120 allowance). Note that discounts on lens options will not apply at Walmart.

… keeps on track with his medicine

…takes long hikes not worrying about running out of medication

…grabs dinner with friends with the money he is saving

…kicks back by the pool instead of making a monthly pharmacy trip

Gets a 90-day supply, so he…

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Join Us At A Health Fair!

The Superior Court will have a series of Health Fairs for this year’s Open Enrollment. We would like to invite all Court employees to come and join us. All our carriers will attend and will have benefits materials and giveaways. Every employee that attends will have a chance to win one of our many donated raffle prizes.

Santa Maria, CA Santa Barbara, CA

October 15 October 16

SM Superior Court, Jury Bldg. SB Superior Court, Jury Bldg.

312 E. Cook Street 1108 Santa Barbara Street

3:00pm – 5:00pm 3:00pm – 5:00pm

NOTE: Flu and pneumonia shots will be available at the Health Fairs and the Open Enrollment meeting. EPO members, please bring your Express Scripts ID card with you if you would like a free vaccination. HDHP members, please bring your Blue Shield ID card.

Open Enrollment Meeting

Lompoc, CA

October 17

Lompoc Superior Court

115 Civic Center Plaza, Dept. 2

3:00pm – 5:00pm

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Benefit Plan Information for 2020

The Superior Court will not be making any plan changes to any of the offered benefit plans for the 2020 plan year. All current benefits will remain the same.

The Court will be offering a voluntary Hospital Confinement Indemnity plan through Voya. Information on this new benefit can be found on page 3. You may also attend one of our Health Fairs to obtain detailed information on this new benefit offering.

If you would like to keep your current benefit selections, you do not have to do anything during Open Enrollment unless you want to participate in a Flexible Spending Account (FSA) or enroll in the new Voya Hospital Confinement Indemnity plan for 2020.

During Open Enrollment, remember that:

• You must enroll in an FSA account every year; your account does not roll over. • The Courts will continue to contribute $900 ($37.50 per pay period) to a Health

Savings Account for all employees enrolled in the Blue Shield HDHP. • Premium information is on page 13. Deductions are taken twice monthly rather than

every paycheck. There are no deductions in pay period 1 or pay period 14. • All plan changes must be made online at https://workterra.net. You may add or delete

all benefit plans online except for the FSA. Instructions on how to use Workterra can be found on the Human Resources Forms web page. All changes must be completed by October 31, 2019.

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Who Can You Cover?

WHO IS ELIGIBLE?

Regular Court employees working at least 20 hours or more per week are eligible for the benefits outlined in this overview.

You can enroll the following family members in our medical, dental and vision plans.

• Your spouse (the person who you are legally married to under state law, including a same-sex spouse.)

• Your registered domestic partner is eligible for coverage if you have completed a Domestic Partner Affidavit. Please review the affidavit carefully because it includes important information about the guidelines for adding, ending or changing coverage for your domestic partner. Any premiums for your domestic partner paid for by the Santa Barbara County Superior Court are taxable income and will be included on your W-2. Any premiums you pay for your domestic partner will be deducted on an after-tax basis.

• Your children (including your registered domestic partner's children):

o Under the age of 26 are eligible to enroll in medical coverage. They do not have to live with you or be enrolled in school. They can be married and/or living and working on their own.

o Over age 26 ONLY if they are incapacitated due to a disability and primarily dependent on you for support.

o Named in a Qualified Medical Child Support Order (QMCSO) as defined by federal law.

PROOF OF ELIGIBILITY

Proof of eligibility is required before enrollment of dependents. Eligible documents include:

• Marriage Certificate

• Declaration of Domestic Partner

• Birth Certificate See page 33 for more documentation information.

WHO IS NOT ELIGIBLE?

Family members who are not eligible for coverage include (but are not limited to):

• Parents, grandparents, and siblings.

Please refer to the Appendix section on page 26 to obtain detailed information on eligibility requirements and documentation needed.

WHEN CAN I ENROLL?

Coverage for new employees begins on the 1st of the month following their date of hire.

Open enrollment for current employees is held in October. Open enrollment is the one time each year that employees can make changes to their benefit elections without a qualifying life event.

Make sure to notify Human Resources right away if you do have a qualifying life event and need to make a change (add or drop) to your coverage election. These changes include (but are not limited to):

• Birth or adoption of a baby or child

• Loss of other healthcare coverage

• Eligibility for new healthcare coverage

• Marriage

• Divorce

You have 31 days to make your change.

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Making the Most of Your Benefits Program Helping you and your family members stay healthy and making sure you use your benefits program to its best advantage is our goal in offering this program. Here are a few things to keep in mind

WHEN TO USE THE ER

The emergency room should not be your first choice unless there is a true emergency – a serious or life threatening condition that requires immediate attention or treatment that is only available at a hospital.

WHEN TO USE URGENT CARE

Urgent care is for serious symptoms, pain or conditions that require immediate medical attention but are not severe or life threatening and do not require the use of a hospital or ER. Urgent care conditions include but not limited to: earaches, sore throat, rashes, sprains, flu and fever up to 104.

If you need a medication, you could save money by asking your doctor if there are generics or generic alternatives for your specific medication.

PREVENTIVE OR DIAGNOSTIC?

Preventive care is intended to prevent or detect illness before you notice any symptoms. Diagnostic care treats or diagnoses a problem after you have had symptoms.

Be sure to ask your doctor why a test or service is ordered. Many preventive services are covered at no cost to you. The same test or service can be preventive, diagnostic, or routine

care for a chronic health condition. Depending on why it’s done, your share of the cost may change.

Whatever the reason, it’s important to keep up with recommended health screenings to avoid more serious and costly health problems down the road.

Sample screening tests covered under Preventive: alcohol misuse (screening/counseling), bone density, depression screening, Hepatitis C virus (high risk individuals), HIV screening and counseling, tobacco use, tuberculosis screening, violence (interpersonal and domestic) screening and counseling, prostate and cervical cancer screenings.

Immunizations covered under Preventive: Hepatitis A and B, Human papillomavirus (HPV), Influenza (flu), Measles/mumps/rubella (MMR), Meningococcal (meningitis), Pneumococcal (pneumonia), Varicella (chickenpox) and Zoster (shingles). There are age requirements for some of these immunizations.

PHARMACY ITEMS

Be aware that some medications have age or prior authorization requirements. Make sure you obtain all medications at in-network pharmacies and use Express Scripts Smart90 Program (page 4) for all maintenance medications to save money. Remember to inform your doctor/pharmacist of all the medications and supplements that you are taking to make sure there are no drug interactions.

VIRTUAL DOCTOR’S VISIT

Access a doctor 24/7/365. Visit www.teladoc.com/bsc for more information.

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Medical Medical coverage provides you with benefits that help keep you healthy, like preventive care screenings and access to urgent care. It also provides important financial protection if you have a serious medical condition.

Santa Barbara County Superior Court gives you a choice between two medical plans through Blue Shield of California.

Blue Shield Medical EPO

Blue Shield Medical – HDHP

(High Deductible Health Plan)

In-Network In-Network Out-Of-Network

Annual Deductible $0 - Individual

$0 - Family

$1,500 - Individual

$3,000 - Family

$1,500 (combined with in-network)

$3,000 (combined with in-network)

Annual Out-of-Pocket Max

$1,500 - Individual

$3,000 - Family

$4,500 - Individual

$9,000 - Family

$4,500 (combined with in-network)

$9,000 (combined with in-network)

Lifetime Maximum Unlimited Unlimited Unlimited

Office Visit

Primary Provider $20 copay Plan pays 80% after deductible Plan pays 60% after deductible

Specialist

Home Visit

Virtual Visit - Teladoc

$20 copay

$50 copay

$20 copay

Plan pays 80% after deductible

Plan pays 80% after deductible

$40 copay after deductible

Plan pays 60% after deductible

Plan pays 60% after deductible

Not Covered

Preventive Services Plan pays 100% Plan pays 100% Plan pays 60% after deductible

Chiropractic Care

$20 copay (combined outpatient rehab (up to 30 visits/ cal year)

Plan pays 80% after deductible (up to 20 visits per calendar year)

Plan pays 60% after deductible (combined with in-network limit of 20 visits/calendar year)

Lab and X-ray Plan pays 100% Plan pays 100% after deductible

Plan pays 60% after deductible

Inpatient Hospitalization

$250 admission copay then plan pays 80%

Plan pays 80% after deductible Plan pays 60% after deductible (up to $600 per day)

Outpatient Surgery Plan pays 100% Plan pays 80% after deductible Plan pays 60% after deductible (up to $350 per day)

Urgent Care $20 copay Plan pays 80% after deductible Plan pays 60% after deductible

Emergency Room $100 copay then plan pays 100% (copay waived if admitted)

Plan pays 80% after deductible Plan pays 80% after deductible

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Prescription Drugs

Prescription drug coverage provides a benefit that is important to your overall health. If you enroll in medical coverage, you will automatically receive coverage for prescription drugs. Here are the prescription drug plans that are offered with our Blue Shield EPO and HDHP plans.

Blue Shield EPO

(Administered by Express Scripts)

Blue Shield HDHP

(Administered by Blue Shield)

In-Network In-Network Out-Of-Network

Prescription Drug Deductible

$25 per individual; $75 per family for Preferred and Non-Preferred Brand

Combined with medical Combined with medical

Annual Out-of-Pocket Limit

$5,100 Ind/$10,200 family Combined with medical Combined with medical

Pharmacy

Generic $10 copay Plan pays 80% after deductible

Plan pays 80% after deductible

Preferred Brand $35 copay after Rx deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Non-preferred Brand $50 copay after Rx deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Supply Limit 30 days 30 days 30 days

Mail Order

Generic $20 copay Plan pays 80% after deductible

Not covered

Preferred Brand $70 copay after Rx deductible

Plan pays 80% after deductible

Not covered

Non-preferred Brand $100 copay after Rx deductible

Plan pays 80% after deductible

Not covered

Supply Limit 90 days 90 days Not applicable

If you are viewing electronically, click on the icon to watch a video on Prescription Drugs / Dos and Don’ts or go to our website where you will find an electronic copy of this booklet.

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Dental

Regular visits to your dentist can protect more than your smile; they can help protect your health. Recent studies have linked gum disease to damage elsewhere in the body and dentists are able to screen for oral symptoms of many diseases including cancer, diabetes, and heart disease.

The Santa Barbara County Superior Court gives you a choice between two dental plans through Delta Dental. Please refer to the Court’s custom Delta Dental website to look up providers, www.deltadentalins.com/superiorcourtofcactyofsantabarbara. If you elect the DHMO plan, you must select a DeltaCare USA primary dentist, otherwise, you will be auto assigned a dentist near your home zip code.

Delta Dental DHMO -DeltaCare USA Delta Dental PPO

In-Network In-Network* Delta Dental Premier or Out-Of-Network*

Calendar Year Deductible

$0 - Individual

$0 - Family

$50 - Individual

$100 - Family

$50 – Individual (combined with in-network)

$100 – Family (combined with in-network)

Annual Plan Maximum N/A $1,500 per person $1,500 per person (combined with in-network)

Waiting Period None None None

Diagnostic and Preventive

Plan pays 100% Plan pays 100% Plan pays 100%

Basic Services

Fillings Various copays apply Plan pays 90% after deductible

Plan pays 80% after deductible

Root Canals Various copays apply Plan pays 90% after deductible

Plan pays 80% after deductible

Periodontics Various copays apply Plan pays 90% after deductible

Plan pays 80% after deductible

Major Services Various copays apply Plan pays 60% after deductible

Plan pays 50% after deductible

Orthodontic Services

Orthodontia Plan pays 100% up to Lifetime Maximum

Plan pays 50% up to $1,500 Lifetime Maximum (Calendar deductible does not apply)

Plan pays 50% up to $1,500 Lifetime Maximum (Calendar deductible does not apply)

Lifetime Maximum $1,900 Child

$2,100 Adult

$1,500 Child

$1,500 Adult

$1,500 Child or Adult (combined with in-network)

*Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and 80th percentile for non-Delta dentists.

If viewing electronically, click on the icon to view an Understanding Your Dental Plan or go to our website where you will find an electronic copy of this booklet.

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Vision

Routine vision exams are important, not only for correcting vision but because they can detect other serious health conditions.

We offer you a vision plan through Vision Service Plan (VSP).

VSP Vision

In-Network Out-Of-Network*

Examination

Benefit $10 copay then plan pays 100% Plan pays up to $45

Frequency 1 x every 12 months In-network limitations apply

Eyeglass Lenses

Single Vision Lens $10 copay then plan pays 100% of basic lens

Up to $30

Bifocal Lens $10 copay then plan pays 100% of basic lens

Up to $50

Trifocal Lens $10 copay then plan pays 100% of basic lens

Up to $65

Frequency 1 x every 24 months In-network limitations apply

Frames

Benefit Up to $120

Up to $70 at Costco

20% off amount over your allowance

Up to $70

Frequency 1 x every 24 months In-network limitations apply

Contacts (In Lieu of Glasses)

Benefit Up to $120 Up to $105

Frequency 1 x every 24 months 1 x every 24 months

*The Out-of-Network amounts are reimbursement amounts not copayment amounts.

USING YOUR VSP BENEFIT IS EASY

• Find a VSP doctor at www.vsp.com under the VSP Signature network.

• At your appointment, say you have VSP. No ID card required, but you can print one online.

NEW FOR 2020!

You may now go to Walmart to obtain your glasses! VSP will pay at the same level as Costco.

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Cost of Coverage

The amount that you pay for your coverage is outlined below and depends on whether you have employee only coverage or cover dependents.

In general, you pay for health coverage before federal, state, and social security taxes are withheld, so you pay less in taxes. Please note that domestic partner contributions, are regulated by the IRS and generally must be made on an after-tax basis. Similarly, the company contribution toward the cost of domestic partner coverage and his/her dependents is taxable income to you. Contact your tax advisor for more details on how this tax treatment applies to your specific situation.

Rates noted below are twice monthly.

Medical Premium

Court Contribution*

Pre-Tax Employee Cost

After-Tax Employee Cost

Blue Shield EPO Medical Plan Group #W0052121

Employee Only 367.50 (367.50) 0.00 With 1 Dependent 681.00 (367.50) 313.50 Two + Dependents 1,068.50 (367.50) 701.00 Employee + Domestic Partner 681.00 (367.50) 0.00 313.50

Employee + 1 Dep & Domestic Partner 1,068.50 (367.50) 313.50 387.50

Employee + 2 or more Dep & Dom Partner 1,068.50 (367.50) 701.00 Blue Shield HDHP Medical Plan Group #W0052151

Employee Only 325.00 (325.00) 0.00 With 1 Dependent 600.50 (325.00) 275.50 Two + Dependents 944.50 (325.00) 619.50 Employee + Domestic Partner 600.50 (325.00) 0.00 275.50

Employee + 1 Dep & Domestic Partner 944.50 (325.00) 275.50 344.00

Employee + 2 or more Dep & Dom Partner 944.50 (325.00) 619.500

*Court contribution will be pro-rated for part-time employees.

Rates noted below are twice monthly.

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Dental

Premium Court

Contribution* Pre-Tax

Employee Cost After-Tax

Employee Cost

Delta Dental PPO Group #16479

Employee Only 22.80 (13.02) 9.78 With 1 Dependent 43.75 (13.02) 30.73 Two + Dependents 67.25 (13.02) 54.23 Employee + Domestic Partner 43.75 (13.02) 9.78 20.95

Employee + 1 Dep & Domestic Partner 67.25 (13.02) 30.73 23.50

Employee + 2 or more Dep & Dom Partner 67.25 (13.02) 54.23 Delta Dental HMO DeltaCare USA, Group #76836

Employee Only 20.16 (13.02) 7.14 With 1 Dependent 33.15 (13.02) 20.13 Two + Dependents 50.32 (13.02) 37.30 Employee + Domestic Partner 33.15 (13.02) 7.14 12.99

Employee + 1 Dep & Domestic Partner 50.32 (13.02) 20.13 17.17

Employee + 2 or more Dep & Dom Partner 50.32 (13.02) 37.30

*Court contribution will be pro-rated for part-time employees

Vision

Premium Pre-Tax

Employee Cost After-Tax

Employee Cost

Vision Service Plan (VSP)

Employee Only 3.50 3.50 With 1 Dependent 4.90 4.90 Two + Dependents 8.65 8.65 Employee + Domestic Partner 4.90 3.50 1.40

Employee + 1 Dep & Domestic Partner 8.65 4.90 3.75

Employee + 2 or more Dep & Dom Partner 8.65 8.65

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Life and Disability Insurance If you have loved ones who depend on your income for support, having life and accidental death insurance can help protect your family's financial security.

BASIC LIFE

Basic Life Insurance pays your beneficiary a lump sum if you die. The cost of coverage is paid in full by the Courts. Coverage is provided by Voya Financial.

Basic Life Amount $20,000

LONG-TERM DISABILITY

The Courts cover all regular employees working 20 hours or more with a Long-Term Disability Insurance plan. The plan pays 60% of your monthly earnings with a minimum of $100 to a maximum amount which is dependent on your job classification. You must be disabled for 60 days before the plan begins to pay benefits.

SUPPLEMENTAL LIFE and AD&D

Supplemental Life and AD&D Insurance allows you to purchase additional life insurance to protect your family's financial security. Coverage is provided by Voya Financial.

Employee Supplemental Life Amount

Can elect from $20,000 to $500,000 in increments of $10,000 ($10,000 of AD&D is included for a minimal fee)

Spouse or Domestic Partner Supplemental Life Amount

Can elect from $20,000 to $500,000 in increments of $10,000 not to exceed 100% of Employee’s Supplemental Life Insurance amount. Employee must have coverage.

Child(ren) Supplemental Life Amount

Can elect $5,000 or $10,000 (unmarried child from birth up to age 26). Employee must have coverage.

NOTE: Your amount of Supplemental Life and AD&D will decrease to 65% on your 65th birthday, to 50% of original coverage on your 70th birthday and 30% of the original coverage at age 75.

Beneficiary Reminder: Make sure that you have named a beneficiary for your life insurance benefit. It's important to know that many states require that a spouse be named as the beneficiary, unless they sign a waiver.

Evidence of Insurability: Depending on the amount of coverage you select, you may need to submit an Evidence of Insurability form, which involves providing the insurance company with additional information about your health.

Taxes: Due to IRS regulations, a life insurance benefit of $50,000 or more is considered a taxable benefit. You will see the value of the benefit included in your taxable income on your paycheck and W-2.

NOTE: Rates for this plan can be found on page 18.

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Voluntary Accident and Critical Illness Insurance VOLUNTARY PERSONAL ACCIDENT

Voluntary Personal Accident Insurance (PAI) is offered by Voya Financial. Premiums are based on a flat rate per $1,000 for Employee only or Family (Spouse/Domestic Partner and Child). Evidence of Insurability (EOI) is not required. Rates for this plan can be found online.

Employee Voluntary Personal Accident

Can elect from $25,000 to $300,000 in $25,000 increments not to exceed 10 times annual salary

Family Voluntary Personal Accident

• Spouse/Domestic Partner – receives 50% of Employee’s Personal Accident Insurance

• Child (each) – receives 10% of Employee’s Personal Accident Insurance

VOLUNTARY COMPASS ACCIDENT

Voluntary Compass Accident Insurance is offered by Voya Financial. This policy helps you pay for the out-of-pocket costs you may experience after an accident. The policy pays a lump sum amount depending on the type of injuries you have sustained such as broken bones, torn ligaments, burns, as well as for expenses from hospitalizations, the ER, office visits or physical therapy. You may use this amount to pay for everyday living expenses or to pay healthcare costs. The policy also has an annual Wellness Benefit that pays you $100 for completing a screening, an additional $100 for a covered spouse and $50 for a child.

VOLUNTARY CRITICAL ILLNESS

Critical Illness Insurance is an affordable way to protect against the financial stress of a serious illness. It pays a lump-sum benefit if you are diagnosed with a covered illness or condition. This policy is in addition to your health coverage. You may use this benefit to pay:

• Medical expenses • Child Care • Home health costs • Mortgage payment/rent and home

maintenance • Any other every day expenses

This policy offers an annual Wellness benefit that provides a $150 reimbursement for each covered employee and spouse who completes a covered health screening. Child benefit is 50% of employee amount with a maximum of $300 in child wellness benefit.

Coverage is provided by Voya Financial.

Employee Voluntary Critical Illness

Can elect from $5,000 to $20,000 in $5,000 increments.

Spouse Voluntary Critical Illness

Can elect $5,000 or $10,000.

Must have employee coverage.

Child Voluntary Critical Illness

Can elect $1,000. $2,500. $5,000 or $10,000.

Must have employee coverage.

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Wellness Benefit At A Glance What is a Wellness Benefit?

A Wellness benefit is a rider that is included on your voluntary Accident, Critical Illness and Hospital Indemnity Plan. It provides an annual payment if you complete a preventive health screening test. You only need to complete one preventive health screening test. This one test can be used for any or all three benefit plans. The Accident, Critical Illness and Hospital Indemnity plan each has a Wellness benefit. Your spouse and/or dependents covered under your plan also have a Wellness benefit.

What type of preventive health screening tests are eligible?

Preventive health screening tests include but are not limited to:

Blood test for triglycerides

Serum Protein Electrophoresis

Fasting blood glucose test Annual physical exam

Pap smear Breast ultrasound, sonogram, MRI

Thermography CA 125 (ovarian cancer)

Sigmoidoscopy Chest x-ray PSA ( prostate cancer) Tests for STIs

CEA (blood test for colon cancer)

Mammography Hearing test Ultrasounds for abdominal aortic aneurysms

Bone marrow testing Colonoscopy Routine eye exam Hemoglobin A1C

Cholesterol test CA 15-3 (breast cancer) Routine dental exam Bone density

Hem occult stool analysis

Stress test on bicycle or treadmill

Well child/preventive exam to age 18

Electrocardiogram (EKG)

How do I file a claim?

You can easily file a claim online. 1. Go to voya.com/claims 2. Scroll down to the “Have a Wellness Benefit Claim?” section and click the “Submit your claim”

button. 3. Check all products that apply – Accident, Critical Illness, Hospital Indemnity 4. Click “Continue” and follow the screen prompts. Once all questions are answered, click

“Submit” Your Group Name is: Santa Barbara Superior Court

Your Group Number is: 00680974

Don’t forget to claim your Wellness dollars every year!

Make it a habit to do so right after your annual physical exam.

If viewing electronically, click on the icon to view a video on How To File A Claim or go to our website where you will find an electronic copy of this booklet.

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Voluntary Insurance Rates

Supplemental Life Insurance Rates

Personal Accident Insurance (PAI) Rates

Voluntary Compass Accident Insurance Rates

Voluntary Hospital Confinement Indemnity Insurance Rates

Employee and Spouse Supplemental Life Insurance Rates

Age Cost per $1,000 of Coverage

Under 25 $0.03

25-29 $0.03

30-34 $0.045

35-39 $0.05

40-44 $0.06 45-49 $0.09

50-54 $0.165

55-59 $0.26 60-64 $0.405

65-69 $0.775

70+ $1.255

Supplemental Accidental Death and Dismemberment (AD&D) Insurance Rates

Coverage Type Cost of Coverage Employee

Supplemental AD&D

$0.13

Child Life Insurance Rates

Coverage Levels Cost of Coverage

$5,000 each child

$10,000 each child

$0.525

$1.05

Coverage Type Cost per $1,000 of Coverage

Employee Only $0.02

Employee + Family $0.28

Employee Employee and Spouse Employee and Children Family

$4.57 $7.58 $8.10 $11.10

Coverage Type

Employee Only $13.59

Employee + Spouse $26.52

Employee + Child(ren) $20.15

Employee + Family $33.08

Semi-Monthly (24) Rates

Semi-Monthly (24) Rates - Includes Wellness Benefit

Semi-Monthly (24) Rates

Semi-Monthly (24) Rates

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Voluntary Critical Illness Insurance Rates

Non-Tobacco Tobacco

Issue Age $5,000 $10,000 $15,000 $20,000 Issue Age $5,000 $10,000 $15,000 $20,000

Under 20 $3.70 $5.45 $7.20 $8.95 Under 20 $4.95 $7.95 $10.95 $13.95

20-24 $3.70 $5.45 $7.20 $8.95 20-24 $4.95 $7.95 $10.95 $13.95

25-29 $3.98 $6.00 $8.03 $10.05 25-29 $5.50 $9.05 $12.60 $16.15

30-34 $4.05 $6.15 $8.25 $10.35 30-34 $5.85 $9.75 $13.65 $17.55

35-39 $4.78 $7.60 $10.43 $13.25 35-39 $7.33 $12.70 $18.08 $23.45

40-44 $6.18 $10.40 $14.63 $18.85 40-44 $10.10 $18.25 $26.40 $34.55

45-49 $8.08 $14.20 $20.33 $26.45 45-49 $13.85 $25.75 $37.65 $49.55

50-54 $10.25 $18.55 $26.85 $35.15 50-54 $18.13 $34.30 $50.48 $66.65

55-59 $12.33 $22.70 $33.08 $43.45 55-59 $22.15 $42.35 $62.55 $82.75

60-64 $15.18 $28.40 $41.63 $54.85 60-64 $27.50 $53.05 $78.60 $104.15

65-69 $21.30 $40.65 $60.00 $79.35 65-69 $38.98 $76.00 $113.03 $150.05

70+ $29.58 $57.20 $84.83 $112.45 70+ $54.88 $107.80 $160.73 $213.65

Non-Tobacco Tobacco

Issue Age $5,000 $10,000 Issue Age $5,000 $10,000 Under 20 $3.28 $4.60 Under 20 $4.23 $6.50

20-24 $3.28 $4.60 20-24 $4.23 $6.50 25-29 $3.60 $5.25 25-29 $4.93 $7.90 30-34 $4.60 $7.25 30-34 $6.73 $11.50 35-39 $5.50 $9.05 35-39 $8.45 $14.95 40-44 $7.23 $12.50 40-44 $11.88 $21.80 45-49 $9.88 $17.80 45-49 $17.10 $32.25 50-54 $13.48 $25.00 50-54 $24.33 $46.70 55-59 $17.45 $32.95 55-59 $32.20 $62.45 60-64 $22.45 $42.95 60-64 $42.18 $82.40 65-69 $30.93 $59.90 65-69 $58.60 $115.25 70+ $35.98 $70.00 70+ $67.60 $133.25

Coverage Amount Rate

$1,000 $1.84

$2,500 $2.34

$5,000 $3.18

$10,000 $4.85

Employee Coverage - Semi-Monthly (24) Rates - Includes Wellness Benefit

Spouse Coverage -Semi-Monthly (24) Rates - Includes Wellness Benefit

Children Coverage - Semi-Monthly (24) Rates - Includes Wellness Benefit

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Other Programs

SOLERA – Lifestyle Change Program

Blue Shield offers a free comprehensive 16-week program which helps qualified members lose weight, adopt healthy habits and significantly reduce their risk of developing type 2 diabetes. The program meets weekly for 16 weeks and then monthly for the balance of the year. You may choose from an array of national programs like Weight Watchers, Jenny Craig, Retrofit or HealthSlate. To find out if you qualify for this preventive program, go to www.solera4me.com/eia and take a one minute quiz. If you qualify, use Blue Shield of CA as your health plan and your Blue Shield Member ID number to enroll.

Health Coaching Weekly Lessons Integrated devices Group Support

Call Solera at 877.486.0141 if you have questions.

CARRUM HEALTH – Voluntary Surgery Benefit

Carrum Health, your voluntary surgery benefit, has inpatient and outpatient surgeries at Centers of Excellent medical centers. 80 outpatient procedures are available at Hoag Orthopedic Institute in Orange County. Inpatient surgeries are at Stanford Healthcare, Scripps Health Hospital and St. Johns Health Center.

Why Carrum?

• Highest quality surgeons • No medical bills! Coinsurance and

deductible waived* • Travel expenses covered 100% for two • Your own personal Concierge that will:

o Help with forms o Gather medical records o Schedule surgery o Make travel arrangements o Coordinate post-discharge care

FIND OUT MORE: Visit: carrum.me/EIAHEALTH

Text: “EIA” to 555888 Call us: 1-888-855-7806

*Due to IRS regulations on HDHP plans, the deductible applies but the coinsurance is waived.

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HEALTHCARE ADVOCACY PROGRAM

CareCounsel is an independent organization and is not part of your health plan. They are a benefits advocacy program that can help you navigate the complexities of your benefits plan. Your CareCounselor can answer benefits questions, guide you to the appropriate resources, and intervene on your behalf until your issue/problem is resolved. This program is free and completely confidential.

Areas where they can help are:

· Making the best choices from your healthcare options during Open Enrollment

· Getting the most of your healthcare dollars

· Helping find a physician and access care

· Seeking second opinions

· Obtaining necessary authorizations

· Troubleshooting medical claims/bills

· Grievances and appeals

· Connecting you with the Court’s healthcare resources

MEET BEN-IQ

Ben-IQ is a free app that includes much of the information that's included in this overview, but in a place that's always at your fingertips — your smartphone. Ben-IQ is available for Android and iPhone.

GETTING STARTED WITH BEN-IQ

1. Download and launch the app.

2. Enter your assigned username: Santa Barbara Courts

3. Read and agree to the Terms and Conditions.

Take a tour of Ben-IQ and review plan summaries, and important contacts like our nurse line and EAP. Store and organize ID cards using your phone's camera, and much more! Be sure to share Ben-IQ with your covered family members too.

Click and watch our Ben-IQ video! https://www.brainshark.com/alliant/beniq-hd

Contact CareCounsel at 1.888.227.3334 or go online to www.carecounsel.com

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HEALTH SAVINGS ACCOUNT (HSA)

A Health Savings Account (HSA) is available to employees who participate in the Blue Shield High Deductible Health Plan (HDHP). This is a tax-advantaged savings account through Sterling HSA that allows you to save pre-tax dollars to pay for qualified health expenses.

An HSA allows you to: • Save toward medical expenses (including dental and vision), up to IRS maximums (see Table

below) • Have your contributions deducted on a pre-tax basis • Change your contribution amount at any time • Roll the funds to the following year (this is not a “use it or lose it”

plan) • Keep the account; it is portable; it goes with you if you leave

employment • Use a debit card to pay for qualified medical expenses • Use the funds to pay for IRS tax dependents even if they are not

enrolled in the HDHP

HSA Contribution Limits for 2020

Annual Single Contribution Maximum $3,550*

Annual Family Contribution Maximum $7,100*

Annual Catch-Up Contribution Maximum (for HSA participants that are 55 years or older)

$1,000

*Limit includes contributions from the Court.

The Court will contribute $900 annually over 26 pay periods into your Sterling HSA account.

If viewing electronically, click on the icon to view a HDHP video or go to our website where you will find an electronic copy of this booklet.

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FLEXIBLE SPENDING ACCOUNT (FSA)

Santa Barbara County Superior Court offers you the opportunity to participate in a Healthcare and/or Dependent

Care Flexible Spending Account (FSA).

Healthcare FSA Account

This plan allows you to pay for eligible out-of-pocket healthcare expenses with pre-tax dollars. Eligible expenses include medical, dental, or vision costs including plan deductibles, copays, coinsurance amounts, and other non-covered healthcare costs for you and your tax dependents. For 2020, you can set aside up to $2,700.

Due to IRS guidelines, employees who are enrolled in a HDHP plan cannot have a HealthCare FSA if they also have a Health Savings Account (HSA). For this reason, the IRS does allow you to open a Limited-Purpose Flexible Spending Account where eligible expenses are limited to qualified dental and vision expenses only. You may use this account to pay dental fillings, braces, crowns, vision exams, eyeglasses, vision correction procedures and more.

Dependent Care FSA Account

This plan allows you to pay for eligible out-of-pocket dependent care expenses with pre-tax dollars. Eligible expenses may include day care centers, in-home child care, and before or after school care for your dependent children under age 13. Other individuals may qualify if they are considered your tax dependent and are incapable of self-care. It is important to note that you can access money only after it is placed into your dependent care FSA account.

All caregivers must have a tax ID or Social Security number. This information must be included on your federal tax return. If you use the dependent care reimbursement account, the IRS will not allow you to claim a dependent care credit for reimbursed expenses. Consult your tax advisor to determine whether you should enroll in this plan. For 2020, you can set aside up to $5,000 per household for eligible dependent care expenses.

IMPORTANT CONSIDERATIONS

• The FSA plans have an added feature (Grace Period) that allows you to continue to incur new claims up to 03/15/21, with any remaining funds from your 2020 elected amount. Expenses must be submitted for reimbursement no later than 05/30/21.

• Elections cannot be changed during the plan year, unless you have a qualified change in family status (and the election change must be consistent with the event).

• FSA funds can be used for you, your spouse, and your tax dependents only.

• Keep your receipts. In most cases, you'll need to provide proof that your expenses were considered eligible for IRS purposes.

• You must spend all the monies in your account or you will lose it. You may not carry over an FSA balance from one year to another.

Note: The 2020 FSA maximum amount may change in October when the IRS announces the maximum limits for 2020.

If viewing electronically, click on the icon to view an FSA or go to our website where you will find an electronic copy of this booklet.

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TRANSIT & PARKING FLEXIBLE SPENDING ACCOUNT (FSA)

Santa Barbara County Superior Court allows you to participate in a Parking/Transit Flexible Spending Account. Use the money in our WageWorks Commuter Program for all of your eligible work-related transit and parking expenses. Ineligible expenses include tolls, car maintenance, carpools and gasoline

Work related transit - these consist of vouchers, passes, tokens and fare cards for transportation via bus, commercial vanpool or train. The maximum IRS allowed amount for 2020 is $265 per month.

Parking expenses – these include parking at or near work, parking at or near a transportation site and Park and Ride expenses. The maximum IRS allowed amount for 2020 is $265 per month.

Learn how much you can save by going to CommuterWorks4Me.com/takecare.

Note: The 2020 Transit and Parking maximum allowed amounts may change in October when the IRS announces the maximum limits for 2020.

EMPLOYEE ASSISTANCE PROGRAM

There are times when everyone needs a little help or advice. The confidential Employee Assistance Program (EAP) through MHN Inc. can help you with things like stress, anxiety, depression, chemical dependency, relationship issues, legal issues, parenting questions, financial counseling, and dependent care resources. Best of all, it's free for you and your family.

MHN has a variety of tools and resources online that will help you; understand your EAP benefits and how to access them, handle workplace issues effectively, improve your health and wellbeing. Visit us online at www.members.mhn.com.

Immediate 27/7/365 access.

Need to talk to someone right away? Call us at 800.242.6220.

24/7/365 Free Confidential

If viewing electronically, click on the icon to view an EAP video or go to our website where you will find an electronic copy of this booklet.

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For Assistance

Plan Type Provider Phone Number Website

Medical Blue Shield EPO and HDHP

855.256.9404 www.blueshieldca.com/csac

Pharmacy Express Scripts for EPO only

800.711.0917 www.express-scripts.com

Medical Carrum Health 888.855.7806 my.carrumhealth.com/EIAHEALTH

Dental Delta Dental DHMO

DeltaCare USA

800.422.4234 www.deltadentalins.com/superiorcourtofcactyofsantabarbara

Dental Delta Dental

PPO & Premier

800.765.6003 www.deltadentalins.com/superiorcourtofcactyofsantabarbara

Vision Vision Service Plan (VSP)

800.877.7195 www.vsp.com

FSA WageWorks 888.295.5656 www.takecarewageworks.com

HSA Sterling HSA 800.617.4729 www.sterlinghsa.com

EAP MHN 888.227.2204 www.members.mhn.com

To register, use company code: sbcountycourts

Human Resources

805.882.4739 www.sbcourts.org/gi/hr/benefits.asp

email: HumanResources@sbcourts.org

YOUR BENEFIT ADVOCATE CAN ALSO HELP:

CareCounsel 888.227.3334 8:00am – 4:30pm, M-F www.carecounsel.com

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Key Terms

MEDICAL/GENERAL TERMS

Allowable Charge - The most that an in-network provider can charge you for an office visit or service.

Balance Billing - Non-network providers are allowed to charge you more than the plan's allowable charge. This is called Balance Billing.

Coinsurance - The cost share between you and the insurance company. Coinsurance is always a percentage totaling 100%. For example, if the plan pays 70%, you are responsible for paying the remaining 30% of the cost.

Copay - The fee you pay to a provider at the time of service.

Deductible - The amount you have to pay out-of-pocket for expenses before the insurance company will cover any benefit costs for the year (except for preventive care and other services where the deductible is waived).

Explanation of Benefits (EOB) - The statement you receive from the insurance carrier that explains how much the provider billed, how much the plan paid (if any) and how much you owe (if any). In general, you should not pay a bill from your provider until you have received and reviewed your EOB (except for copays).

Family Deductible - The maximum dollar amount any one family will pay out in individual deductibles in a year. IMPORTANT: If you enroll for family coverage on the 2020 plan, one or more family members will need to meet the deductible.

Individual Deductible - The dollar amount a member must pay each year before the plan will pay benefits for covered services. Important: If you enroll for family coverage on the 2020 plan, the individual deductible does not apply.

In-Network - Services received from providers (doctors, hospitals, etc.) who are a part of your health plan's network. In-network services generally cost you less than out-of-network services.

Out-of-Network - Services received from providers (doctors, hospitals, etc.) who are not a part of your health plan's network. Out-of-network services generally cost you more than in-network services. With some plans, such as HMOs and EPOs, out-of-network services are not covered.

Out-of-Pocket - Healthcare costs you pay using your own money, whether from your bank account, credit card, Health Reimbursement Account (HRA), Health Savings Account (HSA) or Flexible Spending Account (FSA).

Out-of-Pocket Maximum – The most you would pay out-of-pocket for covered services in a year. Once you reach your out-of-pocket maximum, the plan covers 100% of eligible expenses.

Preventive Care – A routine exam, usually yearly, that may include a physical exam, immunizations and tests for certain health conditions.

PRESCRIPTION DRUG TERMS

Brand Name Drug - A drug sold under its trademarked name. A generic version of the drug may be available.

Generic Drug – A drug that has the same active ingredients as a brand name drug, but is sold under a different name. Generics only become available after the patent expires on a brand name drug. For example, Tylenol is a brand name pain reliever commonly sold under its generic name, Acetaminophen.

Dispense as Written (DAW) - A prescription that does not allow for substitution of an equivalent generic or similar brand drug.

Maintenance Medications - Medications taken on a regular basis for an ongoing condition such as high cholesterol, high blood pressure, asthma, etc. Oral contraceptives are also considered a maintenance medication.

Non-Preferred Brand Drug - A brand name drug for which alternatives are available from either the plan's preferred brand drug or generic drug list. There is generally a higher copayment for a non-preferred brand drug.

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Preferred Brand Drug - A brand name drug that the plan has selected for its preferred drug list. Preferred drugs are generally chosen based on a combination of clinical effectiveness and cost.

Specialty Pharmacy - Provides special drugs for complex conditions such as multiple sclerosis, cancer and HIV/AIDS.

Step Therapy - The practice of starting to treat a medical condition with the most cost effective and safest drug therapy and progressing to other more costly or risky therapy, only if necessary.

DENTAL TERMS

Basic Services - Generally include coverage for fillings and oral surgery.

Diagnostic and Preventive Services - Generally include routine cleanings, oral exams, x-rays, sealants and fluoride treatments. Most plans limit preventive exams and cleanings to two times a year.

Endodontics - Commonly known as root canal therapy.

Implants - An artificial tooth root that is surgically placed into your jaw to hold a replacement tooth or bridge. Many dental plans do not cover implants.

Major Services - Generally include restorative dental work such as crowns, bridges, dentures, inlays and onlays.

Orthodontia - Some dental plans offer Orthodontia services for children (and sometimes adults too) to treat alignment of the teeth. Orthodontia services are typically limited to a lifetime maximum.

Periodontics - Diagnosis and treatment of gum disease.

Pre-Treatment Estimate - An estimate of how much the plan will pay for treatment. A pre-treatment estimate is not a guarantee of payment.

If viewing electronically, click on the icon to view a Benefits Term video or go to our website where you will find a copy of this booklet.

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Important Plan Notices and Documents

CURRENT HEALTH PLAN NOTICES

Notices must be provided to plan participants on an annual basis and are available on our benefits website www.sbcourts.org/gi/hr/benefits.asp for your reference. They include:

• Medicare Part D Notice Describes options to access prescription drug coverage for Medicare eligible individuals.

• Women's Health and Cancer Rights Act Describes benefits available to those that will or have undergone a mastectomy.

• HIPAA Notice of Special Enrollment Rights Describes when you can enroll yourself and/or dependents in health coverage outside of open enrollment.

• Notice Grandfathered Plan Status Notifies you that a plan is grandfathered and does not include all Affordable Care Act (ACA) provisions.

• Children's Health Insurance Program Reauthorization Act (CHIPRA) Describes availability of premium assistance for Medicaid eligible dependents.

• Newborns’ and Mothers’ Health Protection Act Describes the right of mothers and newborns to hospital length of stay after childbirth.

• Notice of Availability of HIPPA Privacy Notice Notifies you of your right to receive a copy of the Insurance Carriers’ HIPPA Privacy Notice.

• ACA 1557 Notice Notifies you that the Court complies with Federal civil rights laws and does not discriminate on basis of race, color, national origin, age, disability, or sex.

CURRENT PLAN DOCUMENTS

Important documents for our health plans can be found on our benefits website, www.sbcourts.org/gi/hr/benefits.asp and include:

Evidence of Coverage (EOCs)

An Evidence of Coverage, or EOC, is the legal document for describing benefits provided under the plan as well as plan rights and obligations to participants and beneficiaries. The following EOC plan descriptions is/are available:

• Blue Shield EPO Plan • Blue Shield HDHP Plan

Summary of Benefits and Coverage (SBCs)

A Summary of Benefits and Coverage (SBC) is a document required by the Affordable Care Act (ACA) that presents benefit plan features in a standardized format. The following SBCs are available:

• Blue Shield EPO Plan

• Blue Shield HDHP Plan

Paper copies of these documents and notices are available if requested. If you would like a paper copy, please contact Human Resources at 805.882.4739.

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Appendix A. ELIGIBILITY RULES

Eligible Employees and Retirees You are eligible to enroll in Court medical, dental, vision and applicable voluntary benefits plans if:

• you are a regular employee of the Court working at least 20 hours per week, or

• you are an extra-help employee working in a grant funded position working 20 or more hours per week and are expected to be employed for six or more months (medical, dental and vision only), or

• you are an extra-help employee who has worked an average of 30 hours per week in the measurement period (medical, dental and vision only; see below for terms),

• you are a qualified retiree who is currently receiving a retirement allowance from the Court.

The following terms and periods (as defined by the IRS) apply to extra-help employees:

• Upon Hire o Initial Measurement Period = 12 months from date of hire. o Administration Period = from the end of the initial measurement period to the end of the first

calendar month beginning on or after the end of the initial measurement period. o Stability Period = 12 months beginning on the first day after the Administration Period.

• Ongoing Employees (an employee who has been employed by the Court for at least one complete standard measurement period.

o Standard Measurement Period = October 15th of the previous year to October 14th of the current year.

o Administration Period = October 15th through December 31st. o Stability Period = January 1st to December 31st.

Example: An extra help employee is hired on July 15 year 1.

• Initial Measurement period = July 15 year 1 to July 14 year 2. • Administration period = July 14 year 2 to August 31 year 2. • Stability period = September 1 year 2 to August 31 year 3.

This employee’s hours will be measured again in year 2 using the same dates as the initial measurement period as they have not yet been employed through one full measurement period. In the third year they will move to the standard measurement period in October.

If they meet the eligibility requirements, coverage will continue from August 31 year 4 to December 31 year 4 at which time they will become an ongoing employee. Eligible Dependents Eligible employees and retirees who enroll in Court benefits plans may also enroll their eligible dependents in the Plan. Eligible dependents include:

• the employee’s or retiree’s lawful spouse as defined by applicable law, or legally registered domestic partner,

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• the employee’s or retiree’s natural children, stepchildren, foster children, or adopted children of which the employee is the legal guardian who are under the age of 26, or your eligible physically or mentally handicapped children who depend on you for support, regardless of age,

• The child of a covered domestic partner who satisfies the same conditions as listed above for natural children, stepchildren, foster children or adopted children, and in addition is not a “qualifying child” (as that term is defined in the Internal Revenue Code) of another individual.

• any child named in a qualified medical child support order for which an eligible employee or retiree is required to provide health coverage.

Eligible dependents do not include any person on active duty in the Armed Forces of the United States or any person covered as an employee or retiree under the Medical or Dental Plan. If both partners in a marriage or domestic partnership are eligible to be participants, then they may both be eligible for dependent benefits. Their children may be eligible to be enrolled as a dependent of both parents. Documentary proof of dependent eligibility must be provided to Human Resources at the time of enrollment. Examples of types of documentation accepted may be requested from the Human Resources Department. Waiver of Coverage If an eligible employee chooses to waive health insurance coverage, they must do so by indicating their intention to waive coverage through the normal enrollment procedures. You must provide proof of alternative coverage to Human Resources in order to waive medical coverage. Enrollment Requirements New Hires: Eligible employees who want coverage under the Court’s benefits plans must enroll through the normal enrollment procedures prior to their 30th day of employment. Retirees: Retirees must enroll by completing the applicable enrollment form and submitting it when they complete and return the Court’s Application for Retirement form. Dependents: If an eligible employee or retiree wants their eligible dependents covered under the Court’s benefits plans at the same time their initial coverage begins, the eligible dependents must be included in the initial enrollment process. If an eligible employee or retiree acquires eligible dependents after his initial enrollment, the dependent(s) must be enrolled within 31 days of the date they are acquired. A newborn dependent child is automatically covered from birth for 31 days. In order for coverage to be continued beyond the first 31 days, the enrollment process must be completed within 31 days following birth. 60 days are allowed for an event that is allowed under the Children's Health Insurance Program (CHIP) Reauthorization Act. Late enrollment: If enrollment does not take place as provided above, the eligible employee or retiree may enroll himself and/or his eligible dependents in the Court’s benefits plans only during the Court’s annual open enrollment period except as provided below under “special enrollment.” Special enrollment: If an eligible employee or retiree does not enroll himself and/or eligible dependents in the Medical or Dental Plan because he or they were covered under another group health plan or had other health insurance coverage at the time enrollment in the Medical or Dental Plan was declined, the eligible employee or retiree may enroll himself and/or his eligible dependents in the Medical or Dental Plan if there is a qualifying status change. Qualified Status Changes include:

• Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a spouse;

• Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent child;

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• Change in employment status that affects benefit eligibility, including the start or termination of employment by you, your spouse, or your dependent child;

• Change in work schedule, including an increase or decrease in hours of employment by you, your spouse, or your dependent child, including a switch between part-time and full-time employment, that affects eligibility for benefits;

• Change in a child's dependent status, either newly satisfying the requirements for dependent child status or ceasing to satisfy them;

• Change in place of residence or worksite, including a change that affects the accessibility of network providers;

• Change in your health coverage or your spouse's coverage attributable to your spouse's employment; • Change in an individual's eligibility for Medicare or Medicaid; • A court order resulting from a divorce, legal separation, annulment, or change in legal custody (including

a Qualified Medical Child Support Order) requiring coverage for your child; • An event that is allowed under the Children's Health Insurance Program (CHIP) Reauthorization Act.

When Coverage Begins If enrollment takes place during the Court’s annual open enrollment period, coverage will begin on January 1. If enrollment is delayed because of other health coverage, coverage will begin on the date the other coverage is lost provided you enroll in the Court’s plan within 31 days from the loss of coverage. Following are the date coverage begins when enrollment takes place when a person is first entitled to enroll:

• New Hires: o Regular Employees: When enrollment requirements are met, coverage begins on the first day of

the month after the employee’s first day of employment. o Extra Help Employees: As determined by initial measurement period (page 1).

• New Retirees: When the enrollment requirements are met, coverage beings on the first day of the month following retirement or, if coverage has been extended under COBRA, on the date that coverage ends.

• Dependents: When enrollment requirements are met, coverage for eligible dependents begins on the date the eligible employee’s or retiree’s coverage begins or, if acquired after that date, the date the dependent becomes an eligible dependent.

• For marriage or domestic partnership, the effective date will be the first day of the first month following receipt of your request for enrollment;

• For birth, the effective date will be the date of birth; • For a child placed for adoption, the effective date will be the date the Member, spouse, or Domestic

Partner has the right to control the child’s health care. When Coverage Ends Unless a special extension applies, coverage under the Court’s benefits plans will end on the earliest of the following dates:

• for eligible employees and their eligible dependents only, the last day of the month during which the eligible employee’s employment terminates or otherwise ceases to meet the requirements of an eligible employee;

• for retirees and their eligible dependents only, the last day of the month a retiree no longer qualifies for coverage because his retirement allowance from the Court ceases;

• for dependents only, on the last day of the month during which the dependent no longer qualifies as an eligible dependent;

• the date of complete termination of the Court’s benefits plans or upon the effective date of an amendment to the Court’s benefits plans which excludes the covered person from such status;

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• the last day of the month following the date the Court receives written authorization from the eligible employee or retiree to terminate his health coverage. Important note to retirees: if dental coverage is voluntarily terminated by a retiree, it cannot be reinstated or added at a later date, even during an annual open enrollment period;

• the last day of the month for which any required self-payment was made for this coverage if the next self-payment is not paid when due.

Special Extensions Physical or Mentally Handicapped Child: If a dependent child is physically or mentally handicapped on the date coverage would otherwise end because of age, the child’s coverage will be continued for as long as the eligible employee or retiree is covered under the plan provided the handicap continues and the child continues to qualify as an eligible dependent in all aspects except age. The Court may require from time to time a physicians’ statement certifying the physical or mental handicap. Leave of Absence: Eligible employees may continue coverage during a leave of absence provided they continue twice monthly contributions as agreed upon with the Court and they comply with the applicable provisions of the Court’s Leave of Absence Policy. If the Leave of Absence extends for greater than 18 months, the employee will be responsible for the full benefits’ premium payment beginning in the 19th month of the leave of absence. Employees entering the Armed Forces of the United States: If an eligible employee goes into active military service (including periodic reserve training) for any of the Armed Forces of the United States for up to 31 days, coverage may continue during the period of that leave, if such employee continues to pay his required contribution for coverage, if any. The Court will continue its contribution for coverage during such military leave. If an eligible employee goes into active military service for any of the Armed Forces of the United States for more than 31 days, coverage may continue for up to 18 months or the period of such military leave, whichever is shortest, if such employee pays the full cost of the coverage during the military leave. Whether or not an eligible employee elects to continue coverage, coverage will be reinstated on the first day they return to active employment with the Court if they are released under honorable conditions and they return to work on whichever of the following dates is applicable:

• on the first full business day following completion of their military service for a leave of 30 days or less,

• within 14 days of completing their military service for a leave of 31 to 180 days,

• within 90 days of completing their military service for a leave of more than 180 days.

When coverage under the Medical & Dental Plan is reinstated, all provisions, limitations and exclusions of the Plan will apply to the extent that they would have applied if he had not taken military leave and his coverage had been continuous under the Plan. The foregoing, however, does not apply to coverage for any illness or injury caused or aggravated by military service, as determined by the Veterans Administration.

For further information see the individual plan Evidence of Coverage documents which are the controlling source of eligibility information.

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B. ELIGIBILITY DOCUMENTATION

Dependent Type Required Documentation Resources to Obtain Documentation

Spouse (same or opposite gender)

Marriage Certificate and the portion of your most recent joint Federal or State Tax Return that lists filing status and includes the name(s) of the dependent spouse and/or children OR a current utility bill showing the spouse’s name and employee’s address.

• County office that issued original marriage certificate.

• Personal tax records/IRS/CA Franchise Tax Board.

• Utility companies. • www.vitalchek.com

Registered Domestic Partner State of California, County or City issued Declaration/Certificate of Domestic partnership and the portion of your most recent joint State Tax Return that lists filing status and includes the name of the domestic partner OR a current utility bill showing the spouse’s name and employee’s address.

• County/City office that issued original certificate.

• Personal tax records/CA Franchise Tax Board.

• Utility companies.

Dependent child by birth, related to employee or dependent stepchild(ren)

Birth Certificate-must include parent’s name, and/or copies of any court orders, divorce decrees or other legal documents relating to custody, health coverage or income tax exemptions.

• County office that issued original birth certificate.

• Hospital in which child was born.

• US Department of State (for children born outside of the US)

• www.vitalchek.com

Dependent child by adoption Final adoption papers, and/or copies of any court orders, divorce decrees or other legal documents relating to custody, health coverage or income tax exemptions.

• State agency that issued final adoption papers.

• Adoption agency that issued placement papers.

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Employee Benefits Brochure designed and developed by

In conjunction with Santa Barbara County Superior Court, January 2020